胫骨平台后外侧骨折入路及手术策略进展

胫骨后外侧平台骨折是目前创伤骨科治疗难点和热点之一。因腓骨小头遮挡,后外角韧带复合体、邻近腓总神经和腘血管限制使得该部位骨折难以显露和固定。入路选择和治疗方法存在很大争议。因此,需要熟悉治疗此类骨折的手术入路及其特点。临床关注的入路主要包括:改良的前外侧入路(Gerdy结节截骨,腓骨头截骨,股二头肌腓骨头截骨,股骨外上髁截骨),后外侧入路(Carlson后外侧入路,经腓骨颈截骨及腓骨小头上)及后内侧入路。胫骨后外侧平台骨折入路需要考虑骨折类型、其他象限受累情况、局部软组织条件及所用内固定进行确定。需要考虑体位、骨折形态、内固定生物力学稳定性对治疗的影响。根据文献报道提出累及后外象限的胫骨平台骨折入路选择和内固定流程。     

胫骨前外侧截骨开门法治疗胫骨平台后外侧塌陷骨折

胫骨平台后外侧塌陷骨折手术时,传统的前外侧入路因显露不佳使学者近年来多采用后外侧入路或行腓骨小头截骨入路[1]。但膝关节后外侧入路解剖复杂,损伤血管神经可能性大,而且出于保护胫前动脉需要不能向下过度延长切口。笔者自2009年5月~2012年7月尝试采用胫骨前外侧截骨开门法治疗胫骨后外侧平台塌陷骨折21例,安全有效,报告如下。     

经腓骨截骨入路治疗胫骨平台后外侧骨折

目的探讨经腓骨截骨入路治疗胫骨平台后外侧骨折的疗效。方法采用经腓骨截骨入路治疗45例胫骨平台后外侧SchatzkerⅡ～Ⅴ型骨折患者。定期随访摄X线片评估骨折愈合情况,记录并发症情况。末次随访时,采用Rasmussen放射评分标准评估膝关节X线片表现,按Rasmussen评分标准评定膝关节功能。结果 45例患者均获得随访,时间9～35个月。骨折愈合时间为10～18周。随访期间未见复位丢失。术后1例出现腓总神经损伤症状,腿远端外侧、足背局部出现感觉减退,术后4周恢复。末次随访时,Rasmussen放射评分为14.0～18.0分,其中优35例,良10例;膝关节活动度-5°～135°;膝关节功能Rasmussen评分为21～30分,其中优38例,良7例。结论经腓骨截骨入路治疗胫骨平台后外侧骨折暴露充分,复位及固定满意,术后膝关节稳定性及功能恢复良好。     

经腓骨后外侧入路治疗胫骨平台后外侧骨折

目的 探讨采用经腓骨截骨的后外侧入路来治疗胫骨平台后外侧骨折的临床经验。方法 自2010年6月至2013年7月,采用经腓骨截骨的后外侧入路,后侧或后侧联合外侧支撑钢板固定的方式治疗胫骨平台后外侧骨折的患者共11例,男8例,女3例;年龄33~65岁,平均47.8岁。按AO/OTA分型原则进行分型,其中41-B-2.2.4型2例;41-B-3.1.2型9例。结果 术后X线片示所有患者均达到解剖复位。随访时间为12~24个月,平均17.1个月。骨折愈合时间为9~13周,平均11.6周,随访过程中未见高度丢失,Rasmussen放射评分16~18分,平均17.6分。膝关节功能HSS评分为86~100分,平均93.8分。结论 经腓骨截骨的后外侧入路来治疗胫骨平台后外侧骨折可以清晰暴露后外侧骨折块,方便进行后侧支撑钢板固定,同时可以暴露外侧平台,尤其适用于后外侧骨折合并外侧平台劈裂的病例。     

经前方劈裂骨折线关节内截骨复位内固定治疗Schatzker Ⅱ型胫骨平台骨折疗效观察

目的 观察经前方劈裂骨折线关节内截骨复位内固定治疗Schatzker Ⅱ型胫骨平台骨折疗效,评价该入路的有效性与可行性。方法 回顾性分析自2015-04—2019-10经前方劈裂骨折线关节内截骨复位内固定治疗的12例Schatzker Ⅱ型胫骨平台骨折。采用前外侧入路显露胫骨平台的上表面,先于胫骨关节面下约2 cm经前方骨折线横行截骨,再根据塌陷的部位在后方经关节面作一纵形截骨线。取出截骨块,经截骨窗可以很好地显露外侧胫骨平台塌陷的关节面。结果 12例均获得随访,随访时间平均19(12～24)个月。术后复查X线片与CT显示骨折复位与内固定位置满意,胫骨髁部骨折复位解剖学Rasmussen评分为14～18分,平均16分。随访期间所有患者的骨折均愈合良好,骨折愈合时间为4～7个月,平均5.7个月。末次随访膝关节功能HSS评分为91～95分,平均93.6分。结论 经前方劈裂骨折线关节内截骨复位内固定治疗SchatzkerⅡ型胫骨平台骨折可以充分显露塌陷的关节面,在直视下进行精确复位固定,有效恢复关节面的平整性,术后允许患者进行早期膝关节功能锻炼。     

胫骨外髁截骨联合内外侧双钢板固定治疗胫骨平台外后髁骨折

目的 探讨胫骨外髁截骨联合内外侧双钢板固定治疗胫骨平台外后髁骨折的临床疗效. 方法 2008年1月至2010年5月共收治17例胫骨平台外后髁骨折患者,男13例,女4例;年龄24 ～ 59岁,平均40.8岁.骨折按Schatzker分型:V型10例,Ⅵ型7例.均采用胫骨外髁截骨、前外侧联合后内侧切口双钢板内固定.术后12周内患肢不负重. 结果 17例患者术后获12 ～ 17个月(平均14.3个月)随访.17例患者骨折均获愈合,愈合时间平均为14周(12～18周).术后1年膝关节功能Rasmussen 评分为18 ～ 26分,平均23.6分,其中优13例,良3例,差1例,优良率为94.1％.结论 胫骨外髁截骨显露胫骨平台外后髁骨折联合内外侧双钢板固定是治疗胫骨平台外后髁骨折的一种有效方法.     

经腓骨截骨入路治疗胫骨平台后外侧骨折的疗效观察

 目的 探讨经腓骨截骨入路治疗胫骨平台后外侧骨折的疗效。方法 自2009年8月至2011年8月,采用经腓骨截骨入路治疗17例胫骨平台后外侧骨折患者,男12例,女5例;年龄24～76岁,平均37.8岁。按Schatzker胫骨平台骨折分类法：Ⅱ型骨折8例,Ⅲ型骨折3例,Ⅴ型骨折6例。所有患者随访中摄X线片评估骨折愈合情况,记录随访过程中出现的并发症,并采用Rasmussen放射评分标准对患者膝关节的X线表现进行评估,根据末次随访结果采用Rasmussen评分标准评定膝关节功能。结果 17例患者均获得随访,随访时间为9～35个月,平均18个月。骨折愈合时间为10～18周,平均13．5周。随访期间未见高度丢失,术后1例出现腓总神经损伤症状,小腿远端外侧、足背出现局部感觉减退,术后2周恢复。Rasmussen放射评分14．0～18．0分,平均17．5分。膝关节活动度-5°-0°-135°,平均活动范围123．5°。膝关节功能按照Rasmussen评分为22~30分,平均26.9分。结论 经腓骨截骨治疗胫骨平台后外侧骨折暴露充分,复位及固定满意,不会出现血管神经损伤及膝关节屈曲挛缩畸形,术后膝关节稳定性及功能恢复良好。     

后内侧及腓骨截骨双切口手术治疗胫骨平台后柱骨折疗效观察

目的探讨后内侧及腓骨截骨双切口L形钢板内固定治疗胫骨平台后柱骨折的疗效。方法自2009-08—2012-09采用后内侧及腓骨截骨双切口L形钢板内固定治疗胫骨平台后柱骨折12例,塌陷骨块复位后造成的骨缺损区以人工骨或自体骨植骨充填,以恢复关节面的平整。L形钢板塑形后置于后外侧与腓骨小头之间,软骨下排钉技术支撑塌陷骨折块。结果本组获得12~38个月随访,平均22个月。骨折愈合时间10~16周,平均13.5周。Rasmussen放射评分14~17分,平均16分,根据标准均达到解剖复位。末次随访时膝关节活动度5°-0°-135°,平均运动范围123.5°。膝关节功能Rasmussen评分22~30分,平均25.3分。结论后内侧及腓骨截骨双切口L形钢板内固定治疗胫骨平台后柱骨折显露充分,复位及固定满意,不会出现血管神经损伤及膝关节屈曲挛缩畸形,术后膝关节稳定性及功能恢复良好。     

胫骨骨折手术治疗后不愈合的原因及预防

目的 探讨胫骨骨折因手术治疗所致不愈合的原因分析及预防方法。方法 对589例胫骨骨折（包括胫腓骨骨折）手术治疗，加压钢板内固定320例，其它固定方法269例，包括外固定架100例；其中121例行骨膜旋转移植，87例行带蒂或带血管复合组织皮瓣移植，112例行腓骨截骨术，97例行植骨术。结果 589例胫骨骨折仅13例发生骨不愈合，6例为坚硬的加压钢板取出后原骨折处再次发生骨折。其余均达骨性愈合，随访平均24个月。结论 正确选择内外固定装置及安放位置，保护好邻近骨膜并作骨膜放旋转移植，必要时作腓骨截骨术，胫骨中下段骨折常规植骨，胫骨骨不愈合和再骨折发生率是可以预防的。     

胫骨平台后外侧髁骨折的治疗及评价进展

胫骨平台后外侧髁骨折(PLCF)是指外侧胫骨平台后1/3的骨折,占所有胫骨平台骨折的15％～44.2％.胫骨平台骨折的分型方法日新月异,但三柱理论仍然被最常用于指导胫骨平台后外侧柱骨折的诊断和治疗;常用治疗胫骨平台后外侧髁骨折的手术入路包括后正中入路、腓骨颈截骨的后外侧入路、经膝关节后外侧入路等,治疗方法除常规的钢板螺...     

胫骨平台后髁骨折的治疗

目的:探讨胫骨平台后髁骨折的治疗方法。方法:9例胫骨平台后髁骨折患者,男6例,女3例;年龄24⁵8岁,平均36岁。左侧2例,右侧7例。骨折类型:后外侧髁骨折5例,后内侧髁骨折1例,双髁骨折3例,采用后内和（或）后外侧入路复位内固定治疗。结果:9例均获随访,随访时间6³2个月,平均18·4个月。患膝关节功能评定按Hohl评分标准:优7例,良2例。关节面未见明显塌陷情况。结论:膝关节的后内和（或）外侧入路较前侧入路能更充分暴露后关节间隙及胫骨平台后髁,为骨折的直视复位和植骨内固定提供了良好的操作空间。     

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment

PurposeThe authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization.MethodsThe preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied.ResultsAccording to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from −1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from −7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws.ConclusionFlexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury’s key features, which may facilitate exposure and enhance fixation strength.     

胫骨平台外侧缘撕脱骨折的特点及临床诊治分析

目的 :探讨膝关节损伤中胫骨平台外侧缘撕脱骨折的特点及临床诊治。方法 :自2011年1月至2015年12月运用关节镜技术微创治疗关节内损伤结合双锚钉内固定胫骨平台外侧缘撕脱骨折29例,男17例,女12例;年龄27~62岁,平均41岁。20例合并前交叉韧带断裂(包含前交叉韧带胫骨止点撕脱骨折),3例合并后交叉韧带断裂,1例同时合并前交叉韧带和后交叉韧带断裂,3例合并侧副韧带撕裂,2例合并胫骨平台骨折(内侧平台骨折和外侧平台骨折各1例)。术前均行X线、CT及MRI检查明确诊断,在受伤后5~14 d进行手术,平均7 d。采用Lysholm膝关节评分对膝关节术前、术后功能进行评价。结果:手术时间40~125 min,平均85 min;出血量10~30 ml,平均15 ml。术后所有患者获随访,时间12~18个月,平均14个月。Lysholm膝关节评分由术前的52.0±4.2明显提高至术后1年的91.9±1.4(t=-49.24,P0.05)。抽屉试验、Lachman试验及侧方应力试验均阴性,骨折均骨性愈合。结论 :胫骨平台外侧缘撕脱骨折提示合并有膝关节静力稳定结构(关节韧带、关节囊、半月板等)的损伤,甚至关节内骨折。常规要行CT和MRI检查,建议行关节镜探查,防止漏诊,以使患者能得到及时、全面的治疗,为膝关节功能最大限度恢复创造有利条件。     

后方入路治疗胫骨平台后方骨折

目的:探讨后方入路治疗胫骨平台后方骨折的骨折类型、手术方法和临床疗效。方法:回顾性分析自2008年6月至2011年2月采用后方入路治疗且随访完整的8例胫骨平台后方骨折,男5例,女3例;年龄23～55岁,平均41.1岁。致伤原因:车祸伤5例,高处坠落伤3例。2例胫骨平台后方冠状面骨折伴后交叉韧带撕脱和1例后外侧平台劈裂伴塌陷骨折采用正后方"S"形入路,2例后内侧平台骨折采用后内侧倒"L"型入路,3例同时累及胫骨平台前后侧及胫骨干骺端骨折者采用后内侧倒"L"形入路联合前外侧入路行钢板螺钉内固定。关节面塌陷者采用同种异体骨或自体髂骨植骨术。结果:所有患者获得随访,时间8～39个月,平均20个月。全部病例获得影像学上的骨性愈合,愈合时间11～21周,平均14.5周。术中未出现血管、神经损伤,术后无一例出现切口感染、内固定松动及断裂。所有患者术后即刻与术后6个月胫骨平台内翻角(TPA)、内外侧平台后倾角(PA)度数均无统计学差异。术后末次随访Rasmussen膝关节功能评分为19～29分,平均25.60分,其中优4例,良3例,可1例。术后末次随访Rasmussen放射学评分14～18分,平均17.25分,其中优6例,良2例。结论:胫骨平台骨折以后侧为主时,后方入路能得到很好的骨折端暴露,有利于直视下复位固定,术后近期疗效满意。     

Proximal avulsion of five ligaments and revised diagonal principle in tibial plateau fractures

PurposeThe aim of the study was to analyze the incidence of proximal avulsion of the five main ligaments and to revise the diagonal tension/compression concept in tibial plateau fractures.MethodsComputed tomographic images of 1263 cases of tibial plateau fractures were retrospectively analyzed by the OTA/AO classification and four-column nine-segment classification. The correlation between proximal avulsion of five ligaments and the injury mechanism was analyzed.ResultsIn total, 1263 tibial plateau fractures in 1253 patients were included. A total of 92 cases (7.3%) associated with proximal avulsions were identified among the 1263 tibial plateau fracture cases obtained from our institution's database. The 92 avulsions occurred in 82 patients, among whom 10 patients had two different avulsions in a single knee. The incidence of proximal avulsion fracture of the medial and lateral collateral ligament was 3.6% (45/1263) and 2.1% (26/1263), respectively. The incidence of avulsion of the anterior cruciate ligament and avulsion of the posterior cruciate ligament was much lower at 0.2% (2/1263) and 0.1% (1/1263), respectively. Proximal avulsion of the patellar ligament occurred in 18 cases (incidence rate = 1.4%). Several combinations of injuries, composed of distal tibial plateau fractures and proximal avulsion of ligaments, were identified.ConclusionsAmong the patients with tibial plateau fracture, the incidence of proximal avulsion of the five ligaments was 7.3% (92/1263). The four-column and nine-segment classification is an exhaustive method for recording injuries in these ligaments. The revised diagonal injury concept is useful for understanding the injury mechanism and choosing the appropriate surgical strategy.     

The incidence of posterior tibial plateau fracture: an investigation of 525 fractures by using a CT-based classification system

Background

Fractures of the tibial plateau are seen frequently in orthopedic trauma units and traditionally classified based on two-dimension plain radiographs with the Schatzker Classification system, the most popular. This system focuses on fractures involving the medial and lateral plateau but does not comment on fractures that involve the posterior aspect of the tibial plateau. The purpose of this study was to investigate the incidence of posterior tibial plateau fracture and propose a new computed tomography (CT)-based three-column classification system to guide fracture treatment.

Methods

Between January 2008 and December 2009, 525 tibial plateau fractures admitted to a level 1 trauma center were retrospectively analyzed by four orthopedic trauma surgeons. Antero-posterior plain radiographs were used for Schatzker classification. CT imaging was used to further classify the fracture types with axial views dividing the plateau into three columns: a lateral, medial, and posterior. Posterior tibial plateau fracture (PTPF) was defined as a fracture with an independent fragment of the posterior column

Results

PTPFs were found in 151 cases and had an incidence of 28.8 % in this studied population. Except for type III, PTPFs were observed in each type of the Schatzker classification system. The Schatzker type VI, V, and IV fractures had the three highest percentages of PTPFs, with 76.1, 51.2, and 22.4 %, respectively.

Conclusions

Fractures of the posterior tibial plateau are not uncommon, especially in high-energy trauma. CT imaging is required to appreciate these fracture patterns, and a three-column classification allows for a better understanding of the fracture morphology and the injury mechanism, which guides surgical management.     

Reinforcement strategy for lateral rafting plate fixation in posterolateral column fractures of the tibial plateau: The magic screw technique

BackgroundA posterolateral column fracture of the tibial plateau (PLCF) is not uncommon, especially lateral and bicondylar tibial plateau fractures. Currently, there is no consensus on the methods of surgical treatment for PLCF, including the surgical approach or the fixation strategy. Though various posterior approaches have been explored and can allow posterior buttress plate fixation, the necessity of a posterior approach with fixation for PLCFs is increasingly questioned. Meanwhile, there is no literature to analyse the morphological features of PLCFs. None of the available surgical techniques can solve all of the problems of PLCFs.MethodsFrom February 2016 to June 2016, an inconsecutive series of 16 patients who suffered Schatzker type II tibial plateau fractures involving the posterolateral column were selected based on an analysis of the morphological characteristics of PLCFs. The patients were all treated by lateral rafting plate fixation with magic screw implantation through the extended lateral approach.ResultsAccording to PLCF morphology, 4 patients had mild slope-type depression fractures (MSDF) of the articular surface, and the other 12 patients had block-type splitting fractures (BSF). After a 12-month follow-up period, there were no complications related to the fixation technique and no significant changes in limb alignment. At the final follow-up, the average range of motion (ROM) of the affected knees was 2.3°−125°, and the average HSS score was 94.2.ConclusionsThe selected patients who suffered Schatzker type II fractures involving the posterolateral column could be successfully treated via lateral rafting plate fixation with the magic screw technique. For PLCF treatment, magic screw fixation is a valuable technique that may reduce the utilization of posterior approaches and posterior fixations.     

The extended posterolateral approach for split depression lateral tibial plateau fractures extending into the posterior column: 2 years follow up results of a prospective study

ObjectiveTo prospectively study the outcome of surgically treated split depression lateral tibial plateau fractures extending into the posterior column using the extended posterolateral approach.MethodsTwenty-one patients with split depression lateral tibial plateau fractures (AO: 41-B3) with extension into the posterior column were treated with open reduction and internal fixation through an extended posterolateral approach with osteotomy of the fibular neck ± Gerdy tubercle. Follow up radiographs was assessed for quality of articular reduction and limb axis. Functional assessment was performed at last follow up using the Tegner–Lysholm score. Complications pertaining to the surgical approach were recorded.ResultsThe approach was performed in 15 patients with a fibular neck osteotomy alone and 6 patients required a Gerdy's tubercle osteotomy also. All fractures and osteotomies had united. Anatomical articular reduction was achieved in 16 patients. Radiological limb alignment was restored in all patients except for a reversed posterior slope in 1 patient. Arthritic changes were seen in 3 patients. The mean Tegner–Lysholm score was 87.3 (range: 76–95) at last follow up. No specific complications related to the surgical approach like common peroneal nerve injury and lateral instability of the knee was encountered.ConclusionThe extended posterolateral approach offers excellent exposure posterior to the fibular head to perform articular reduction and fixation achieving satisfactory radiological and functional results in split depression lateral tibial plateau fractures extending into the posterior column.     

胫骨平台后髁骨折的治疗

目的:探讨胫骨平台后髁骨折的治疗方法。方法:9例胫骨平台后髁骨折患者,男6例,女3例;年龄24~58岁,平均36岁。左侧2例,右侧7例。骨折类型:后外侧髁骨折5例,后内侧髁骨折1例,双髁骨折3例,采用后内和(或)后外侧入路复位内固定治疗。结果:9例均获随访,随访时间6~32个月,平均18·4个月。患膝关节功能评定按Hohl评分标准:优7例,良2例。关节面未见明显塌陷情况。结论:膝关节的后内和(或)外侧入路较前侧入路能更充分暴露后关节间隙及胫骨平台后髁,为骨折的直视复位和植骨内固定提供了良好的操作空间。     

Intra-articular tibial plateau fracture characteristics according to the “Ten segment classification”

BackgroundCurrently existing classifications of tibial plateau fractures do not help to guide surgical strategy. Recently, a segment-based mapping of the tibial plateau has been introduced in order to address fractures with a fracture-specific surgical approach. The goal of the present study was to analyze incidence and fracture specifics according to a new 10-segment classification of the tibial plateau.MethodsA total of 242 patients with 246 affected knees were included (124 females, 118 males, mean age 51.9 ± 16.1 years). Fractures were classified according to the OTA/AO classification. Fracture pattern was analyzed with respect to a 10-segment classification based on CT imaging of the proximal tibial plateau 3 cm below the articular surface.Results161 Patients suffered an OTA/AO type 41-B and 85 patients an OTA/AO type 41-C tibial plateau fracture. Females had an almost seven times higher risk to suffer a fracture due to low-energy trauma (OR 6.91, 95% CI (3.52, 13.54), p < 0.001) than males. In 34% of the patients with affection of the medial tibial plateau, a fracture comminution, primarily due to low-energy trauma (p < 0.001), was observed. In type B fractures, the postero-latero-lateral (65.2%), the antero-latero-lateral (64.6%) and the antero-latero-central (60.9%) segment were most frequently affected. Every second type C fracture showed an unique fracture line and zone of comminution. The tibial spine was typically involved (89.4%). A typical fracture pattern of high-energy trauma demonstrated a zone of comminution of the lateral plateau and a split fracture in the medial plateau. The most frequently affected segments were the postero-latero-central (85.9%), postero-central (84.7%), and antero-latero-central (78.8%) segment.ConclusionPosterior segments were the most frequently affected in OTA/AO type B and C fractures. Acknowledging the restricted visibility of posterior segments, whose reduction and fixation is crucial for long-term success, our findings implicate the use of posterior approaches more often in the treatment of tibial plateau fractures. Also, low-energy trauma was identified as an important cause for tibial plateau fractures.